Category: Success Story Contest

There are four best practice entries published on this weblog in the success story contest (view all entries here). Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner. In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.

Our company was utilizing the Web Based version of the TapRooT® Software globally to perform and record all RCAs but our work is very project-based and often in remote locations with internet connectivity issues. The challenge was to enable unconnected people in the field to use the software but maintain a central database without repetitive data entry tasks. In addition, these remote users needed a way to get feedback on their investigations to improve overall investigation quality.

Action

All field users were set up with Single User Versions of the TapRooT® Software throughout the Business Unit. To make data entry consistent, the Single User Versions of the TapRooT® Software had to have the same pull down menu selection fields that were in the intranet based Enterprise Version. This was made possible by creating lists of the Departments, Equipment, Locations, Classifications, and Users from the Enterprise version of the Software.

Then the “list Import Tool” and the “User Import Tool” were used to populate these fields in the Single User version of the TapRooT® Software. A Single User version Installation and User’s Guide was created for the field users (who had been through the 5-Day TapRooT® Course) who then used the lists and tools to set up their software on their computers. Now, individual users can work on an investigation and export it and e-mail it for others to review at various points in the investigation. When the final report is approved, it can then be imported into the Enterprise version of the TapRooT´® Software, which is the central database for our global operations, and becomes available to anyone with web access.

Results

The flexibility to use the PC based TapRooT® Software in addition to the web based TapRooT® Software has empowered our investigators to utilize the productivity enhancement tools in the TapRooT® Software without having to have internet connectivity. We have seen a significant increase in the number of TapRooT® RCA’s performed on smaller investigations and proactively at our remote locations. In addition, the ability to easily send these reports to others for review and comment has improved the quality.

There are four best practice entries published on this weblog in the success story contest (view all entries here). Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner. In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.

We investigated a Marine incident where an anchor cable picked up tension during maneuvers and caused a job to be stopped. We needed to find the root cause of what happened and make sure that that job and similar jobs could be done safely.

Action

The situation was evaluated with divers and other disciplines, and a decision was made to form investigation team and use TapRooT® to evaluate the incident. After the interviews, the team went back to shore and drew a SnapCharT® to evaluate the information they had collected. When they compared the Captain’s actions and timing to other Captains doing the same type of work in a similar area with similar conditions, the investigation team found that even though the tug captain had many years of experience, he didn’t have experience laying a four point anchor. Thus, the detailed analysis using SnapCharT® and TapRooT® helped the team spot a lack of experience of an otherwise experienced Captain.

Results

We develop a training program for all Captains performing this kind of work. It includes a simulation/practice of anchor laying in a safe area prior to entering the fields. This will ensure training is adequate on laying a four point anchor and eliminate down time and wasted of resources.

There are four best practice entries published on this weblog in the success story contest (view all entries here). Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner. In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.

Entry #2: Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated

TapRooT® investigation often identify actions and conditions that didn’t cause the actual accident being evaluated but that could be significant and, if not corrected, could combine with other factors to cause a future accident.

Action

These factors that the thorough analysis of TapRooT® helped identify are included in the presentation to management at the end of the talk (after the root cause analysis and corrective actions have been reviewed). This review includes explaining and discussing each of these potentially adverse factors with management. At a minimum, management is aware of these potentially adverse factors and the review often leads to discussion of additional corrective actions to address these issues.

Result

Accidents that might have happened are avoided by implementing corrective actions for problems identified during a root cause analysis that didn’t cause that accident but could have cause additional accident and were corrected by proactive corrective actions.

There are four best practice entries published on this weblog in the success story contest (View all entries here). Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner. In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.

Field investigators that, unfortunately, may not be trained in the use of TapRooT® collect initial information and then send it to trained investigators to analyze the root causes of aviation accidents using TapRooT®. The untrained field investigators may not collect all the information needed to complete a SnapCharT® or analyze root causes using the Root Cause Tree® (parts of the TapRooT® System). This sometimes caused the trained investigators to have to go back and ask questions at a later date when those being interviewed might forget or confuse facts that might have been remembered immediately after the accident.

Action

Because the FAA in Alaska is a licensed TapRooT® User, we received permission from System Improvements to develop a pre-printed list of questions for these investigators based on the 15 Questions (Human Performance Troubleshooting Guide) of the Root Cause Tree®. these questions were distributed to the field offices and are used by field investigators to help collect better information.

Results
The field investigators use the list in their interviews and collect better information that is included in their files and sent to the staff personnel that perform the root cause analysis. This result better initial information collection is fewer unanswered questions, less lost information, and better root cause analysis by the trained investigators who use the information when performing the root cause analysis using the TapRooT® System.